Item 041 - Troubles anxieux
Trouble panique Complications • SUICIDE • Trouble anxieux autre • EDM • Addictions • Retentissement socio-professionnel Ttt médicamenteux en 2e intention • ISRS au long cours: paroxétine (Deroxat)
TCC dans le trouble anxieux généralisé
Trouble anxieux généralisé (DSM IV) D L'objet de l'anxiété et des soucis n'est pas limité aux manifestations d'un trouble de l'axe 1, par exemple, l'anxiété ou la préoccupation n'est pas celle d'avoir une attaque de panique (comme dans le trouble panique ), d'être gêné en
troubles Anxieux Et TROUBLE OBSESSIONNEL COMPULSIF
Ce trouble est fréquent, la prévalence étant de 2 à 4 de la population générale L’âge de survenue varie entre î î à ð ð ans, alors que pour le DSM IV, près de la moitié des patients qui consultent pour ce trouble, font état d’un début durant l’enfance ou l’adolescence
Cours De Résidanat Sujet: 69
4 Etablir le diagnostic positif d’un trouble anxiété de séparation de l’enfant, à partir des données anamnestiques et cliniques 5 Différencier les troubles anxieux du trouble obsessionnel compulsif et de l’état de stress post-traumatique, à partir des données anamnestiques et cliniques 6
DÉPRESSION ET ANXIÉTÉ
cLInIQuE Du tROubLE AnxIEux Et DéPRESSIf MIxtE ? Le trouble anxieux et dépressif mixte ( tADM) a été introduit dans la classification CIM-104 en 1992, puis dans le DSM-Iv5 en 1994 sous l’appellation trouble mixte anxiété-dépres-sion (MAD en anglais) Dès le début, cette nouvelle entité diagnostique a fait l’objet
Practice Parameter for the Assessment and Treatment of
episodic panic attacks include at least 4 of 13 symptoms from DSM-IV-TR such as pounding heart, sweating, shaking, difficulty breathing, chest pressure/pain, feeling of choking, nausea, chills, or dizziness Youths with panic disorder fear recurrent panic attacks and their consequences, and they may develop avoidance of
GUIDE DE PRATIQUE POUR LE DIAGNOSTIC ET LE TRAITEMENT
Jusqu’au DSM-III, le TAG était un diagnostic d’exclusion pour les individus qui ne présentaient pas un autre trouble anxieux Depuis le DSM-III-R, on le définit comme un trouble caractérisé par des inquiétudes chroniques et envahissantes Depuis le DSM-IV et selon le
LES TROUBLES SOMATOFORMES
Les deux grandes classifications utilisées en psychiatrie, à savoir la CIM-10 et le DSM-IV, sont globalement superposables en la matière, hormis en ce qui concerne les troubles de conversion qui sont considérés comme troubles dissociatifs selon la CIM-10 Selon le DSM-IV, ils sont classés dans les troubles somatoformes Le trouble
DU TROUBLE PANIQUE, L’AGORAPHOBIE
critères du DSM 5: • des attaques de panique : 9 4 • « presque une attaque de panique » 25 • trouble panique: 3-5 • agoraphobie: 1 5 • 35 à 65 des troubles paniques associées à l’agoraphobie • 45 à 85 des cas d’agoraphobie ne sont pas liées à un trouble panique franc mais à une attaque de panique isolée ou épisodes
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Copyright @ 2007 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
Practice Parameter for the Assessment and Treatment of Children and Adolescents With Anxiety DisordersABSTRACT
This revised practice parameter reviews the evidence from research and clinical experience and highlights significant
advancements in the assessment and treatment of anxiety disorders since the previous parameter was published. It
highlightstheimportanceof earlyassessmentand intervention, gatheringinformation fromvarioussources,assessmentof
comorbid disorders, and evaluation of severity and impairment. It presents evidence to support treatment with
psychotherapy, medications, and a combination of interventions in a multimodal approach.J. Am. Acad. Child Adolesc.Psychiatry,2007;46(2):267Y283.Key Words:anxiety disorders, treatment, practice parameter.
Anxiety disorders represent one of the most common forms of psychopathology among children and adoles- cents, but they often go undetected or untreated. Early identification and effective treatment may reduce the impact of anxiety on academic and social functioning in youths and may reduce the persistence of anxiety disorders into adulthood. Evidence-supported treat- ment interventions have emerged in psychotherapy andmedication treatment of childhood anxiety disordersthat can guide clinicians to improve outcomes in this
population.METHODOLOGY
The list of references for this parameter was
developed by searches ofMedline,OVIDMedline,PubMed, andPsycINFO; by reviewing the bibliogra-
phies of book chapters and review articles; and by asking colleagues for suggested source materials. The searches covered the period 1996 to 2004 and used the following text words: child, adolescent, and anxietydisorders. Each of these papers was reviewed, and onlythe most relevant references were included in the
present document.DEFINITIONS
The terminology in this practice parameter is
consistent with theDSM-IV-TR(American PsychiatricAssociation, 2001). The major anxiety disorders
included in theDSM-IV-TRare separation anxiety disorder (SAD), generalized anxiety disorder (GAD), social phobia, specific phobia, panic disorder (with and without agoraphobia), agoraphobia without panic disorder, posttraumatic stress disorder, and obsessive-compulsive disorder. Selective mutism may have amultifactorial etiology, but it is included in this practice
Accepted September 11, 2006.
This parameter was developed by Sucheta D. Connolly, M.D., Gail A. and Oscar Bukstein, M.D., Co-Chairs, and Valerie Arnold, M.D., Joseph Beitchman, M.D., R. Scott Benson, M.D., Joan Kinlan, M.D., Jon McClellan, M.D., Ulrich Schoettle, M.D., Jon Shaw, M.D., Saundra Stock, M.D., and Heather Walter, M.D. AACAP Staff: Kristin Kroeger Ptakowski. ResearchAssistants: Heena Desai, M.D., and Anna Narejko.
A group of invited experts also reviewed the parameter. The Work Group onQuality Issues thanks Boris Birmaher, M.D., Phillip Kendall, Ph.D., AnnLayne, Ph.D., Barbara Milrod, M.D., Thomas Ollendick, Ph.D., Daniel Pine,
M.D., and Moira Rynn, M.D., for their thoughtful review. This parameter was reviewed at the member forum at the 2004 annual meeting of the American Academy of Child and Adolescent Psychiatry. During September 2005 to January 2006, a consensus group reviewed and finalized the content of this practice parameter. The consensus group consisted of representatives of relevant AACAP components as well as independent experts: William Bernet, M.D., Work Group Co-Chair; Sucheta D. Connolly, M.D., and Gail A. Bernstein, M.D., authors; R. Scott Benson, M.D., Allan K. Chrisman, M.D., and Saundra Stock, M.D., members of the Work Group onQuality Issues; Efrain Bleiberg, M.D., Rachel Z. Ritvo, M.D., and Cynthia W.Santos, M.D., Council Representatives; Gabrielle Shapiro, M.D., Assembly of
Regional Organizations Representative; Boris Birmaher, M.D., and Thomas H. Ollendick, Ph.D., independent expert reviewers; and Amy Hereford, Assistant Director of Clinical Practice. Members of the consensus group were asked to identify any conflicts of interest they may have with respect to their role in reviewing and finalizing the content of this practice parameter. One of the consensus group members was on the speakers_bureau for the following pharmaceutical companies: Eli Lilly, Novartis, Ortho-McNeil, and Shire. This practice parameter was approved by AACAP Council on June 17, 2006.This practice parameter is available on the Internet (www.aacap.org).Reprint requests to the AACAP Communications Department, 3615
Wisconsin Avenue, NW, Washington, DC 20016.
0890-8567/07/4602-0267?2007 by the American Academy of Child
and Adolescent Psychiatry.DOI: 10.1097/01.chi.0000246070.23695.06
AACAP OFFICIAL ACTION
267J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:2, FEBRUARY 2007
Copyright @ 2007 American Academy of Child and Adolescent Psychiatry. Unauthorized reproduction of this article is prohibited.
parameter as research indicates that in most cases children with selective mutism also meet criteria for social phobia (Bergman et al., 2002). This practice parameter addresses all of the above-mentioned anxiety disorders with the exception of posttraumatic stress disorder and obsessive-compulsive disorder, which have their own practice parameters.DEVELOPMENTAL CONSIDERATIONS
Fear and worry are common in normal children.
Clinicians need to distinguish normal, developmentally appropriate worries, fears, and shyness from anxiety disorders that significantly impair a child_s functioning. Infants typically experience fear of loud noises, fear of being startled, and later a fear of strangers. Toddlers experience fears of imaginary creatures, fears of darkness, and normative separation anxiety. School-age children commonly have worries about injury and natural events (e.g., storms). Older children and adolescents typically have worries and fears related to school performance, social competence, and health issues (Muris et al., 1998; Vasey et al., 1994). Fears during childhood represent a normal developmental transition and may develop in child_s functioning. In children of preschool age, there is some emerging evidence that clear subtypes of anxiety may be less differentiated than in primary schoolchildren (Spence et al., 2001). The clinical impact of these anxiety symptoms may be significant even if full criteria are not met.CLINICAL PRESENTATION
Children with anxiety disorders may present with
fear or worry and may not recognize their fear as unreasonable. Commonly they have somatic com- plaints of headache and stomachache. The crying, irritability, and angry outbursts that often accompany anxiety disorders in youths may be misunderstood as oppositionality or disobedience, when in fact they represent the child_s expression of fear or effort to avoid the anxiety-provoking stimulus at any cost. A specific diagnosis is determined by the context of these symptoms.Youths with SAD display excessive and developmen-
tally inappropriate fear and distress concerning separa- tion from home or significant attachment figures. This distress can be displayed before separation or during attempts at separation. These children worry excessively abouttheir own or their parents_safety andhealth when separated, have difficulty sleeping alone, experience nightmares with themes of separation, frequently have somatic complaints, and may exhibit school refusal.Specific phobia is fear of a particular object or
situation that is avoided or endured with great distress. A specific fear can develop into a specific phobia if symptoms are significant enough to result in extreme distress or impairment related to the fear. It is common for youths to present with more than one specific phobia, but this does not constitute a diagnosis of GAD.GAD is characterized by chronic, excessive worry
in a number of areas such as schoolwork, social interactions, family, health/safety, world events, and natural disasters with at least one associated somatic symptom. Children with GAD have trouble control- ling their worries. These children are often perfection- istic, show high reassurance seeking, and may struggle with more internal distress than is evident to parents or teachers (Masi et al., 1999). The worries of GAD are not limited to a specific object or situation, and worry is present most of the time. Social phobia is characterized by feeling scared or uncomfortable in one or more social settings (dis- comfort with unfamiliar peers and not just unfamiliar adults) or performance situations (e.g., music, sports). The discomfort is associated with social scrutiny and fear of doing something embarrassing in social settings such as classrooms, restaurants, and extracurricular activities. These children may have difficulty answering questions in class, reading aloud, initiating conversa- tions, talking with unfamiliar people, and attending parties and social events.It is common for youths with GAD to have worries
in the social domain, but these differ in several ways from worries associated with social phobia. Youths withGAD worry about a variety of areas and not just
performance and social concerns. Youths with GAD worry about the quality of their relationships rather than experiencing embarrassment or humiliation in social situations. The anxiety associated with social phobia usually dissipates upon avoidance or escape from the social situation, but anxiety associated withGAD is persistent.
AACAP PRACTICE PARAMETERS
268J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 46:2, FEBRUARY 2007
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Children with selective mutism persistently fail to speak, read aloud, or sing in specific situations (e.g., school) despite speaking in other situations (e.g., with family and in the home environment). These children may whisper or communicate nonverbally with select individuals such as peers or teachers in some situations. Most of these children also have symptoms of social phobia, and selective mutism may be a subtype or earlier developmental manifestation of social phobia (Bergman et al., 2002). An audio- or videotape that substantiates normal speech and language in at least one setting is recommended, along with ruling out a communication disorder, neurological disorder, or pervasive developmental disorder. Panic disorder is characterized by recurrent episodes of intense fear that occur unexpectedly. These uncued, episodic panic attacks include at least 4 of 13 symptoms fromDSM-IV-TRsuch as pounding heart, sweating, shaking, difficulty breathing, chest pressure/pain, feeling of choking, nausea, chills, or dizziness. Youths with panic disorder fear recurrent panic attacks and their consequences, and they may develop avoidance of particular settings where attacks have occurred (ago- raphobia). Cued panic attacks can occur with any of the anxiety disorders, are common among adolescents, and need to be distinguished from panic disorder, which occurs at a much lower rate (Birmaher and Ollendick,2004). The uncued attacks of panic disorder are not
limited to separation, a feared object/situation, social situations/evaluation, or other environmental cues.EPIDEMIOLOGY
Prevalence rates for having at least one childhood anxiety disorder vary from 6% to 20% over several large epidemiological studies (Costello et al., 2004). Strict adherence to diagnostic criteria and consideration of functional impairment, rather than just the presence of anxiety symptoms, bring the rates down substantially. Referral biases can also dramatically alter prevalence rates. This is complicated by evidence that disability can be associated with subthreshold anxiety symptoms that may not meet full criteria for aDSM-IVdiagnosis (Angold et al., 1999). In general, girls are somewhat more likely than boys to report an anxiety disorder, but more specifically this has been shown for specific phobia, panic disorder, agoraphobia, and SAD. The average age at onset of any single anxiety disorder varies widely between studies, but panic disorder often emerges later in the mid-teen years (Costello et al., 2004). The long-term course of childhood anxiety disorders remains controversial. Despite remission of some initial anxiety disorders, children may develop new anxiety disorders over time (Last et al., 1996) or in adolescence (Aschenbrand et al., 2003). The more severe the anxiety disorder and the greater the impairment in functioning, the more likely it is to persist (Dadds et al., 1997, 1999; Manassis and Hood, 1998). Children and adolescents with anxiety disorders are at risk of developing new anxiety disorders, depression, and substance abuse. A prospective study found anxiety and depressive dis- orders in adolescence predicted approximately a two- to threefold increased risk of anxiety or depressive disorders in adulthood (Pine et al., 1998). A longi- tudinal study of New Zealand children found that adolescents with anxiety disorders have elevated rates of anxiety, major depression, illicit-drug dependence, and educational underachievement as young adults (Woodward and Fergusson, 2001). The sequelae of childhood anxiety disorders include social, family, and academic impairments. Anxiety disorders disrupt the normal psychosocial development of the child (e.g., children with severe social phobia may not have the opportunity to develop independence from adults). Social problems include poor problem-solving skills and low self-esteem (Messer and Beidel, 1994). Anxious children interpret ambiguous situations in a negative way and may underestimate their competencies (Bogels and Zigterman, 2000). In a prospective study, first graders who reported high levels of anxiety symptoms were at significant risk of persistent anxiety symptoms and low achievement scores in reading and math in fifth grade (Ialongo et al., 1995).RISK AND PROTECTIVE FACTORS
adolescents involves an interplay between risk and protective factors (Spence, 2001). Biological risk factors include genetics and child temperament. Several twin studies present evidence of genetic and shared environ- The temperamental style of behavioral inhibition in early childhood increases the likelihood of anxietyANXIETY DISORDERS
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disorders in middle childhood (Biederman et al.,